a nurse is assessing a client who has been diagnosed with obsessive compulsive disorder ocd the client states i know my behavior is unreasonable but i a nurse is assessing a client who has been diagnosed with obsessive compulsive disorder ocd the client states i know my behavior is unreasonable but i
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A client with obsessive-compulsive disorder (OCD) tells the nurse, 'I know my behavior is unreasonable, but I can't help it.' What response should the nurse provide?

Correct answer: D

Rationale: The nurse should acknowledge the client's awareness of the irrationality of their behavior and the feeling of powerlessness to change it. By reflecting the client's feelings, the nurse validates them and opens a discussion on strategies to manage the behavior effectively. Empathy and understanding are key in supporting clients with OCD. Choice A is incorrect because it focuses more on changing the behavior rather than acknowledging the client's feelings. Choice B is incorrect as it does not directly address the client's sense of powerlessness. Choice C is incorrect as it doesn't validate the client's feelings of being unable to control the behaviors.

2. Which valves close during ventricular systole and open during ventricular diastole?

Correct answer: B

Rationale: The correct answer is B: Atrioventricular Valves. The atrioventricular (AV) valves, including the mitral valve and tricuspid valve, close during ventricular systole to prevent backflow of blood from the ventricles into the atria. They open during ventricular diastole to allow blood flow from the atria into the ventricles. Semilunar valves, choice A, are located at the exits of the ventricles and prevent backflow into the ventricles. The mitral valve and tricuspid valve, choices C and D, are specific types of AV valves.

3. What is the first intervention for a patient experiencing anaphylactic shock?

Correct answer: A

Rationale: The correct answer is to administer epinephrine as the first intervention for a patient experiencing anaphylactic shock. Epinephrine is crucial in reversing the allergic reaction and restoring cardiovascular stability. Corticosteroids (Choice B) are not the first-line treatment for anaphylactic shock but may be used as an adjunct therapy. Antihistamines (Choice C) can help relieve itching and hives but are not as effective as epinephrine in treating the systemic effects of anaphylaxis. Oxygen (Choice D) may be necessary to support breathing in severe cases of anaphylaxis, but administering epinephrine takes precedence in the management of anaphylactic shock.

4. Which of the following nursing interventions is important for a client scheduled to have a Guaiac Test?

Correct answer: A

Rationale: The correct answer is A. Turnips, radish, and horseradish are known to cause false-positive results in a Guaiac Test, which is used to detect blood in the stool. Avoiding these foods is crucial to ensure accurate test results. Choice B is incorrect because iron preparations can interfere with the test results. Choice C is incorrect as red meat does not impact the Guaiac Test significantly. Choice D is incorrect as caffeine and dark-colored foods are not relevant to the preparation for a Guaiac Test.

5. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Correct answer: Supplements via nasogastric tube

Rationale: In the scenario of severe dysphagia following a CVA, the client may have difficulty swallowing and require alternative nutritional support. Providing supplements via a nasogastric tube allows for the delivery of essential nutrients directly into the stomach, bypassing the swallowing difficulties. NPO (nothing by mouth) until dysphagia subsides may be too restrictive for the client's nutritional needs. Initiation of total parenteral nutrition is usually reserved for cases where enteral feeding is not possible or contraindicated. A soft residue diet may not be suitable for a client experiencing severe dysphagia.

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